Date of Last Chemotherapy Is Not a Proxy for Deciding When to Stop Treating Metastatic NSCLC

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“Patients, their families, and oncologists recognize the administration of chemotherapy near death as aggressive and poor-quality care,” William F. Pirl, MD, MPH, and colleagues from Massachusetts General Hospital, Boston, wrote in the Journal of Oncology Practice. “However, rates have been slowly rising over the last decade, and 5% to 22% of all patients with advanced cancer receive chemotherapy within 2 weeks of death.”

To identify the processes leading to discontinuation of chemotherapy for patients with metastatic non–small cell lung cancer (NSCLC) at the end of life, the researchers reviewed health records of a prospective cohort of 151 patients with newly diagnosed metastatic NSCLC from a trial of early palliative care. The mean age of patients was 64, and the median number of lines of chemotherapy was 2 to 2.5.

Of 144 patients who died, 81 had received intravenous chemotherapy and 48 had received oral chemotherapies as their final regimen, but 40 of those 48 patients (83.3%) switched from intravenous to oral delivery as their final regimen, the investigators noted. The median time between transitioning from intravenous to oral chemotherapy was 134.5 days. Nine patients did not receive chemotherapy, and six were excluded due to transfer of care or lack of end-of-life data.

The median time between the last intravenous chemotherapy infusion and death was 55 days. “However, almost one-quarter of patients in the sample had no documented decision to discontinue [intravenous] chemotherapy altogether,” the researchers wrote. For patients with documented final decisions, the median time from the decision to the patient’s death was only 20 days.

Five Processes

The authors identified five processes for stopping intravenous chemotherapy: definitive decisions (19.7%), deferred decisions or breaks (22.2%), disruptions for radiation therapy (22.2%), disruptions resulting from hospitalization (27.2%), and no decisions (8.6%). Notes for patients in the no-decision category “suggest that they were unexpected, with some oncologists indicating that patients died a “sudden death.” Nonetheless, several notes raise the possibility that oncologists may not have recognized that patients were close to death,” the authors wrote.

“The five processes occurred at significantly different times before death and, except for definitive decisions, ultimate decisions for no further chemotherapy and referral to hospice were often made months later,” the researchers reported. The processes “seemed to vary based on how confident the oncologist might be in his or her assessment of the time course of a patient’s disease,” the authors added. “Oncologists have been shown to overestimate the survival of their terminally ill patients, which could lead to overconfidence in administering chemotherapy to a patient close to death.”

Study Implications

The “study demonstrates that the date of last chemotherapy treatment is not a proxy for when a decision to stop cancer treatment is made,” the investigators observed. “In this sample of patients with metastatic NSCLC, < 20% had evidence of a definitive decision to stop chemotherapy at the time their chemotherapy was discontinued. For the majority of patients, a substantial amount of time followed the last [intravenous] chemotherapy treatment before a final decision to stop chemotherapy was made.”

Although ASCO “recommends stopping chemotherapy when evidence-based therapies show no benefit and the clinical value of further treatment lacks supporting evidence,” in this study “discontinuation of chemotherapy seemed to occur more often in response to failures rather than futility or lack of benefit,” the authors noted. 

The authors concluded that “chemotherapy discontinuation should not just be considered a date before death; it is a process. Differentiating the processes of discontinuing chemotherapy seems to be meaningful, because these processes occur at significantly different time points before death and may affect subsequent end-of-life care, such as hospice referral, days in hospice, and death in the hospital. Understanding these processes has the potential to reduce the administration of chemotherapy at end of life by identifying not only practices with better outcomes but also factors that trigger earlier discontinuation.” ■

Pirl WF, et al: J Oncol Pract 11:e405-e412, 2015.